Hindawi Publishing Corporation

Journal of Tropical Medicine

Volume 2015, Article ID 262079, 5 pages
http://dx.doi.org/10.1155/2015/262079

Research Article
Newer Classification System for Fissured Tongue:
An Epidemiological Approach

Ramachandran Sudarshan,1 G. Sree Vijayabala,2 Y. Samata,3 and A. Ravikiran3

1
Department of Oral Medicine and Radiology, Best Dental Science College and Hospital, Madurai 625104, India
2
Department of Dentistry, ESIC Medical College and PGIMSR, Ashok Pillar Road, KK Nagar, Chennai 600078, India
3
Department of Oral Medicine and Radiology, SIBAR Institute of Dental Sciences, Guntur 522509, India

Correspondence should be addressed to Ramachandran Sudarshan; sudharshanram@yahoo.co.in

Received 5 June 2015; Accepted 1 September 2015

Academic Editor: Marcel Tanner

Copyright © 2015 Ramachandran Sudarshan et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Introduction. Fissured tongue is a commonly encountered tongue disorder in dental practice. But there is a lack of data on different
pattern, severity, and association of fissuring with various systemic disorders and other tongue anomalies. This study attempts to
establish a classification system for fissured tongue and to know the correlation with the systemic health and other disorders of
the tongue. Materials and Methods. A total of 1000 subjects between the age groups of 10 and 80 years were included in the study.
Pattern of fissuring, allied systemic diseases, and related tongue anomalies were tabulated. Results. Out of 1000 subjects, 387 subjects
presented with fissured tongue. Out of 387 subjects, hypertension was present in 57 cases, 18 subjects had diabetes, and 3 subjects had
both hypertension and diabetes. Central longitudinal type was found to be the most common type of tongue fissuring. Conclusion.
Fissured tongue has been found to be associated with certain systemic disease and further researches are required to know positive
correlation. If a correlation exists, such disorders could be diagnosed earlier by identifying fissured tongue at an earlier age.

1. Introduction the pattern of fissuring, number of fissures on the tongue,

In the medical philosophies, the tongue has been believed to
be an indicator of health for several decades. Customarily, the
tongue is known to be a mirror of the oral and general health.
Hippocrates, Galen, and others considered the tongue as the
barometer of health [1].
In the oral mucosal disorders, tongue lesions constitute
substantial proportions. Variable range of prevalence rates
has been reported in the different regions. This difference may
get along with racial factors, gender and systemic disorders,
and so forth [2].
Fissured tongue is an inherited disorder manifested with
grooves that can vary in size and depth. A definite etiology
does not exist but a polygenic mode of inheritance is postu-
lated. It is an incidental finding diagnosed during the routine
intraoral examination. Usually the fissured tongue is asymp-
tomatic unless entrapment of debris within fissure occurs [3].
The rationale of this present study is a preliminary novel
attempt to derive a classification for fissured tongue based on
and associated symptoms if any. Further correlation of these
findings with the systemic health was also done to find out if
any relevance exists.
2. Materials and Methods
The present study was conducted at the Department of Oral
Medicine and Radiology, SIBAR Institute of Dental Sciences,
Guntur. A total of 1000 consecutive patients among the age
groups of 10 to 80 years were included in the study. All the
patients were accessible at the hospital for regular checkup
and dental treatment. The study was conducted from Febru-
ary 2012 to April 2012 by a single investigator as the fissured
tongue is routinely noted as a common finding on intraoral
examination [3]. Acquiescence to do the study was obtained
from institutional review board and informed consent to
take photographs was given by the study subjects. Only
those patients who gave the informed consent participated
2 Journal of Tropical Medicine

Figure 1: Central longitudinal and coated tongue. Figure 2: Central transverse type.

in the study. A detailed history regarding the demographic

data, systemic health, and associated tongue symptoms was
recorded. Medical history of the subjects was confirmed after
evaluating their recent medical records. The subjects were
seated on the dental chair and were examined using mouth
mirror and straight probe and under illumination with dental
chair light. Study subjects were asked to swish the mouth with
sterile water before performing an intraoral examination of
the tongue. The study subjects were asked to open the mouth
and protrude the tongue as much as possible. The subjects
were examined with sterile gloves and sterile gauze was used
to hold the tip of the tongue to ease complete examination
of the tongue. Clinical analysis regarding the pattern of
fissuring of the tongue, number of fissures in tongue, and
associated tongue anomalies was recorded. Statistical analysis
was performed and a 𝑃 value < 0.05 was considered to be Figure 3: Lateral longitudinal type.
statistically significant.

3. Results the central longitudinal fissure (branching tree

Out of 387 subjects with fissured tongue, 235 (60.7%) were
male subjects and 152 (39.3%) were female subjects.
Based on our observations, we have proposed a novel
method of classification and classified fissured tongue as
follows.
(1) Based on pattern of tongue fissures.
(a) Central longitudinal pattern in 196 (50.6%) sub-
jects (Figure 1): vertical fissure running along
the midline of the dorsal surface of the tongue.
(b) Central transverse pattern in 42 (10.9%) subjects
(Figure 2): horizontal fissure/fissures crossing
the midline.
(c) Lateral longitudinal pattern in 20 (5.2%) sub-
jects (Figure 3): vertical fissure/fissures running
laterally to the midline.
(d) Branching pattern in 68 (17.6%) subjects
(Figure 4): transverse fissures extending from
appearance).
(e) Diffuse pattern in 61 (15.8%) cases (Figure 5):
fissures diffusely distributed across the dorsal
surface of the tongue.
(2) Based on number of tongue fissures.
(a) Mild: tongue fissures ranging from 1 to 3 in
number.
(b) Moderate: tongue with more than 3 fissures.
(c) Severe: tongue with more than 10 fissures.
(3) Based on associated symptoms such as burning sen-
sation and feeling of food lodgement.
(a) Without burning sensation.
(b) With burning sensation.
The predominantly observed fissuring pattern was the
central longitudinal pattern (50.6%) and the least observed
Journal of Tropical Medicine 3

Table 1: Correlation between patterning of fissuring and medical history.

Pattern of fissuring Total

Medical history Central longi. Central trans. Branching Diffuse Lateral longi.
𝑁 % 𝑁 % 𝑁 % 𝑁 % 𝑁 % 𝑁 %
Hypertension (HTN) 20 35.1 15 26.3 4 7.0 14 24.6 4 7.0 57 100.0
Diabetes Mellitus (DM) 2 11.1 2 11.1 7 38.9 7 38.9 0 0.0 18 100.0
Gastritis 4 44.4 0 0.0 3 33.3 2 22.2 0 0.0 9 100.0
Asthma 0 0.0 3 75.0 1 25.0 0 0.0 0 0.0 4 100.0
Trigeminal neuralgia 0 0.0 0 0.0 1 100.0 0 0.0 0 0.0 1 100.0
Syndrome associated 0 0.0 0 0.0 2 100.0 0 0.0 0 0.0 2 100.0
Epilepsy 0 0.0 0 0.0 0 0.0 1 100.0 0 0.0 1 100.0
HTN + DM 3 100.0 0 0.0 0 0.0 0 0.0 0 0.0 3 100.0
HTN + gastritis 2 100.0 0 0.0 0 0.0 0 0.0 0 0.0 2 100.0
Candidiasis + carcinoma 1 100.0 0 0.0 0 0.0 0 0.0 0 0.0 1 100.0
No medical history 164 56.7 22 7.6 50 17.3 37 12.8 16 5.5 289 100.0
Total 196 50.6 42 10.9 68 17.6 61 15.8 20 5.2 387 100.0
Fisher’s Exact Test (<0.001).

Figure 4: Branching type. Figure 5: Diffuse type.

pattern was the lateral longitudinal pattern (5.2%). Fissuring

pattern and number of fissures were correlated with gender
(Pearson Chi-Square is 0.528) results depicted that out of 387
subjects 235 were males and 152 were females.
Pattern of fissuring and number of fissures were corre-
lated and the results showed that the majority of mild cases
were associated with central longitudinal pattern (76.9%)
followed by central transverse (15.3%) and lateral longitudinal
(7.8%) patterns. In moderate group of cases, the majority
belonged to branching type (95.7%) followed by central
transverse type (4.3%). In the severe group of cases, the
majority were of diffuse type (96.8%) followed by branching
type (3.2%) (Fisher’s Exact Test < 0.001).
The majority of patients with fissured tongue were asymp-
tomatic. Out of these 22 subjects, 6 (27.3%) subjects were
in central longitudinal and diffuse types, 4 (18.2%) subjects
were in central transverse and branching types, and 2 (9.1%)
subjects were in lateral longitudinal type.
Pattern of fissuring in patients was correlated with their
medical history. Out of 387 subjects with fissured tongue, 289
subjects were without any medical disorder and the remain-
ing 98 subjects had associated systemic history (Table 1).
Hypertension was present in 57 subjects, 18 subjects had
diabetes, and 3 subjects had both hypertension and diabetes.
Several other systemic disorders also coexisted with the
occurrence of fissured tongue. In our observation it included
asthma, gastritis, trigeminal neuralgia, epilepsy, candidiasis,
carcinoma, and Down’s syndrome. Several associated tongue
disorders have also been observed in the subjects (Table 2).
4. Discussion
Fissured tongue is believed to be a normal variant in fewer
than 10% of the population and perhaps genetically oriented.
4 Journal of Tropical Medicine

Table 2: Correlation between pattern of fissuring and other tongue disorders.

Pattern of fissuring Total

Other tongue disorders Central longi. Central trans. Branching Diffuse Lateral longi.
𝑁 % 𝑁 % 𝑁 % 𝑁 % 𝑁 % 𝑁 %
No tongue disorders 188 53.4 37 10.5 63 17.9 48 13.6 16 4.5 352 100.0
Coated tongue 3 18.8 2 12.5 3 18.8 5 31.3 3 18.8 16 100.0
Oral submucous fibrosis 2 66.7 0 0.0 0 0.0 1 33.3 0 0.0 3 100.0
Depapillated tongue 1 33.3 2 66.7 0 0.0 0 0.0 0 0.0 3 100.0
Hairy tongue 0 0.0 0 0.0 0 0.0 1 100.0 0 0.0 1 100.0
Crenated tongue 0 0.0 0 0.0 1 50.0 0 0.0 1 50.0 2 100.0
Ankyloglossia 1 100.0 0 0.0 0 0.0 0 0.0 0 0.0 1 100.0
Lichen planus (reticular) 0 0.0 1 100.0 0 0.0 0 0.0 0 0.0 1 100.0
Geographic tongue 0 0.0 0 0.0 1 33.3 2 66.7 0 0.0 3 100.0
Erythema 1 100.0 0 0.0 0 0.0 0 0.0 0 0.0 1 100.0
Coated tongue + crenated tongue 0 0.0 0 0.0 0 0.0 1 100.0 0 0.0 1 100.0
Coated tongue + leukoplakia 0 0.0 0 0.0 0 0.0 1 100.0 0 0.0 1 100.0
Coated tongue + OSMF +
0 0.0 0 0.0 0 0.0 1 100.0 0 0.0 1 100.0
depapillated tongue
Depapillated tongue + angular
0 0.0 0 0.0 0 0.0 1 100.0 0 0.0 1 100.0
cheilitis
Total 196 50.6 42 10.9 68 17.6 61 15.8 20 5.2 387 100.0
Fisher’s Exact Test (0.001).

The exact cause of fissured tongue is unidentified; neverthe-
less a polygenic mode of inheritance is alleged because the
situation is seen clustering in families [4].
The asymptomatic fissured tongue is frequently perceived
during intraoral examination as a subsidiary finding. Fissured
tongue may be apparent at birth or become apparent during
later stages with varying degree of depth from 2 to 6 mm [4,
5].
Gender based occurrence of fissured tongue was similar
to a Libyan based adult population study that depicted that
males were commonly affected [6]. But the findings were con-
flicting with the study conducted in Jordan that depicted that
increased prevalence of fissured tongue in female subjects [2].
Fissured tongue has been discussed in the literature based
on position as medial and lateral types. Several variations
have been proposed in the presentation of grooves or furrows
that are typically situated in the dorsolateral area of the
tongue. The next pattern is a central fissure with several
fissures branches at right angles from the central form. In the
severe form, numerous fissures cover the entire dorsal surface
dividing the tongue papillae into multiple separate “icelands”
or lobules which correlates with our diffuse form of fissure
patterning [7].
Burning sensation on the tongue may probably correlate
with the systemic factors and poor oral hygiene. Local factors
implicated in the etiology are ill fitting prosthesis, infection,
parafunctional habits, allergic reaction, xerostomia and gal-
vanism, and so forth [8]. Systemic factors concerned with
burning sensation include medication, anemia, esophageal
reflux, deficiency of vitamin B complex, zinc, iron, esophageal
reflux, and psychological factors [9].
According to the literature, fissured tongue is usually
asymptomatic. Few patients complain of mild pain. The
circumstance is worsened by entrapment of food particles
within the fissures and poor oral hygiene and nutrition [7].
A Hungarian epidemiological survey depicted that fis-
sured tongue was coexistent with diabetes mellitus fol-
lowed by hypertension [10]. But in our study, most of the
systemically debilitated patients had hypertension followed
by diabetes. Most of the hypertensive patients had central
longitudinal pattern of fissuring which was found to be
the common type in patients without any medical history.
Reports suggest that an association exists between geographic
tongue and fissured tongue [11, 12]. Contradicting to the
previous reported studies, coated tongue was found to be
more associated with fissured tongue rather than geographic
tongue which was similar to the observation of the Jordanian
study [2]. Fissured tongue was found to be associated with
certain syndromes like Melkersson-Rosenthal syndrome,
Coffin-Lowry syndrome, Fraser’s Syndrome, Down’s syn-
drome, Oral-Facial-Digital Syndrome Type I, Mohr Syn-
drome, Pierre Robin Syndrome, Maroteaux-Lamy Syndrome,
ECC syndrome, and even Sjögren syndrome [13, 14].
5. Conclusion
This study portrays the newer classification for fissured
tongue, its pattern, frequencies of pattern, associated symp-
toms, and coexisting systemic disorders. The association of
fissured tongue with several systemic disorders has to be
extensively studied in a larger population to validate its
specific relation with systemic illness. Genetic preponderance
Journal of Tropical Medicine 5

of fissured tongue should also be extensively investigated.

Further, if this genetic preponderance is substantiated in mul-
ticentre trials, fissured tongue diagnosed in early stages of life
might be supportive of earlier diagnosis of systemic disorders.

Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.

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